Project Summary/Abstract The Bucharest Early Intervention Project (BEIP)?the only randomized controlled trial (RCT) comparing foster care to institutional care for young children?was designed to address essential questions about human development and when and how to intervene with children exposed to early severe psychosocial deprivation. The BEIP has identified the effects of being raised in large institutions in life on psychopathology and brain structure and function, yet, to date, understanding of the broader health consequences remain unknown. We propose a new assessment of BEIP participants at age 22 years to provide data regarding cardiometabolic risk factors and health behaviors to answer timely questions about the long-term impact of severe early neglect, and the subsequent social experiences and biological risk factors capable of attenuating or amplifying later health risk as these individuals enter adulthood, a key time period for cardiovascular risk. This proposal leverages existing repeated assessments from when the participants were infants and toddlers still living in institutions, after randomization to care as usual or foster care placement, and through age 16. We propose to conduct physical health assessments of BEIP participants at age 22, via clinical examinations, laboratory tests, and self-reported health behaviors. We will assess six outcome domains: 1) body size, fat, and fat distribution; 2) blood pressure; 3) serum-based metabolic risk markers; 4) inflammatory biomarkers, 5) telomere length, and 6) self-reported health behaviors, including sleep, physical activity, alcohol and tobacco use, and diet. In Aim 1, we will examine the long-term effects of early institutionalization and the foster care intervention on cardiometabolic risk in young adulthood. In Aim 2, we will evaluate the moderating effects of stress reactivity in adolescence and telomere attrition from mid-childhood to adulthood on the associations between early institutionalization and foster care on cardiometabolic risks in young adulthood. In Aim 3, we will determine the moderating effects of institutional rearing and foster care on the associations between stressful life events and cardiometabolic risk. Our overarching hypothesis is that severe neglect in early life will negatively impact cardiometabolic wellbeing in young adulthood and that subsequent social experiences and biological risk factors can moderate this trajectory. Our proposal is innovative as the RCT design provides an unparalleled opportunity to test how early psychosocial deprivation and later caregiving shape cardiometabolic risk in early adulthood. Our results will provide the most comprehensive examination to date of the long-term impact of early deprivation and foster care on cardiometabolic risks and related health behaviors. This proposal is significant as it is expected to inform policies pertaining to millions of children exposed to institutional care worldwide and clinical practices for children exposed to the most prevalent form of child maltreatment, neglect.